It is important to understand exactly what, anatomically, the hip area is comprised of, as there are many different structures that can cause pain in the area of the hip. In fact, many runners describe pain as coming from what they think is their hip when the pain is actually coming from other areas nearby, such as the lower back and the rest of the pelvis.

The hip is a joint made by the meeting of the femur, or thigh bone, and part of the ilium, or hip bone. When taken together with the rest of the ilum, the sacrum, and the coccyx and the muscles that attach to these bones, the whole area is known as the pelvic area. The joints between the sacrum and each ilium are known as the sacroiliac joints, one on each side. The major muscles to be concerned with in the hip and pelvic are named below in discussing the specific area of injury.

Functionally, the hip, of course, is subject to impact forces as it plays its role in the running gait. The joint is involved in absorbing the impact of landing, and in the push off and extension of the leg as we propel ourselves forward. These functions cause a lot of stress to be applied to the joint, and if the body cannot handle this stress, overuse injury to the hip will occur. As in all running overuse injuries, the body’s ability to handle the stress of running will be decreased by several factors, such as running too much, too far, and too fast for your training level, not enough recovery time, worn out shoes, and poor nutrition. Also, biomechanical factors intrinsic to your body, such as overpronation, muscle strength imbalances, malignment, leg length inequality, and lack of range of motion/flexibility will decrease the body’s ability to absorb the stress of running without injury. Fortunately, the body does not break down “all at once” (although it may feel that way after a tough race or long run). First to go are usually the “soft-tissues“, meaning the muscles, fascia (which lines the muscles in certain locations), tendons (which attach muscle to bone), bursae (fluid filled sacs that provide gliding of tendon tissue over underlying bone) and ligaments (which attach bone to bone). Also, nerves can be irritated or entrapped. If attention is not paid to these soft-tissues, then the joint and bone tissues will be put at risk for injuries such as degenerative arthritis, hip impingement, labrum tears, and stress fractures, which can be harder to treat. This article will focus on the soft-tissue injuries due to space considerations.

The muscles of the hip must be strong and flexible to give the joint its proper range of motion to do its job. Problems will occur when, because of the factors discussed above, the muscles and/or fascia gradually tighten and lose their normal length. The individual muscle fibers develop adhesions between each other. This change in the muscle itself can be the injury and cause pain upon use. If not released, eventually the tendons, especially where they meet the muscle and where they attach to the bone, can also tighten, swell and weaken. They will not have the strength to do their job. Also, the bursa can get inflamed, but usually only if you totally ignore the pain for weeks or run way longer than you are used to in one run.

What is the first symptom of hip muscle, tendon, or bursa injury? Pain may start as an dull ache during a run or after, although it can be sharper in some muscles or if you have been ignoring the initial pain, and the injury is progressing past the initial stages. Most commonly involved in running are the hip abductors, the gluteus medius and minimus, and the tensor fascia latae (TFL), which is also involved in iliotibial band syndrome (ITBS). (ITBS may be felt at the hip or knee). Also commonly involved are the piriformis and small hip rotator muscles, located just below the gluteals, and the hip extensors (the gluteus maximus and hamstrings). Pain from any of these muscles can be felt at the upper buttock, outer hip, and/or down the outer or back of the thigh. The pain down the thigh is called referred pain, and can be confused with sciatic pain. Next most common are the hip flexors (psoas, sartorius, and rectus femoris), which cause pain in the front of the hip joint and down the front of the thigh and/or groin area. And finally are the adductors, which cause pain in the front and inner thigh,. If your injury is in it’s earliest stages, self-treatment may be helpful. Self-treatment of any of these muscles should start with gentle self-stretching, “rolling” the tight muscle/fascia area on a tennis ball or foam roller, applying ice to the involved areas, and possibly not running for a few days, depending on the severity of symptoms: If you are having pain during of after a run in the muscles that does not go away after two days rest and self-treatment, more rest may be needed. Non-impact cross-training such as the elliptical, cycling, or swimming may be OK. If after a week of rest, pain is still present with daily activities or returns in the same way after a run, professional treatment should be sought.

Professional treatment involves a thorough history and exam to make sure there already is not a joint or bone problem, or a complete muscle tear. The whole lower extremity, from the foot to the lower back, should be examined, and any doctor or therapist you see should be a specialist in running injuries and include a visual or videotape analysis of your walking and running form when the pain subsides enough. This analysis is essential to prevent the injury from reoccurring as it can help identify the predisposing intrinsic factors. If the injury is diagnosed as muscle or muscle and tendon, or also the bursa is involved, manual soft-tissue treatments such as A.R.T. (Active Release Technique), should be used to release the tightened muscle and fascial tissue that is causing the pain. In A.R.T., the doctor or therapist uses his or her hands to contact the tightened area, and either the doctor or patient moves the affected body part to create tension which releases the restriction in the muscle. Treatment will take more visits the longer the injury has been there, because the soft-tissues will be more damaged, or “fibrotic”. Once the muscle and fascia is released, stretches can begin to keep it released. If the area is too tight or swollen for manual treatments, physical modalites such as electric stimulation and/or ultrasound may have to be used first until the area can be treated manually.

The next step in treatment is to correct the training errors and biomechanical deficits discovered throughout the body that caused the injury. The most common general pattern of muscle imbalance related to hip injury is weakness or inhibition of the hip abductors and hip extensors, and tightness of the hip adductors and hip flexors. Other muscle imbalances, such as a weak core, should be addressed as well. Generally, to isolate the weak/inhibited muscles, floor exercises and non-weight bearing exercises involving bands, ankle weights, or machines are first used, progressing to standing exercises with multiple joint motion, such as squats and lunges. Balance exercises on unstable surfaces such as the wobble board, stability ball, and half foam roller are then added, and finally impact activities like plyometric drills (bounding, hopping, and box jumps) are sometimes done. Functional and anatomical leg-length inequality can be corrected by spinal adjustments and heel lifts, respectively. Overpronation secondary to muscle imbalance is corrected with stretching and strengthening, usually of the deep calf muscles, and primary overpronation is corrected with orthotics. Running, starting with even just 10 minutes, then can begin, preferably on soft surfaces such as the reservoir. Resuming running before completing a rehabilitation program invites risk of re-injury, even if you can run pain-free after the soft-tissue treatments! Finally, to keep the injury from reoccurring, as well as to keep your body at it’s highest level of preparedness for running, and maintain longevity in the sport of running, a maintenance, or “prehabilitative” program of self-care is essential! To keep the muscles and other soft-tissues strong and pliable enough to absorb the impact of running, one can continue some of the key rehab exercises, plus use tennis ball/foam-rolling, active stretching pre and post runs, yoga, and strength training including core and upper body postural exercises. Also, it is wise to pay attention to your running form/technique and have a proper training plan for your ability level.

The hamstrings are actually two groups of muscles which run from the pelvis to the upper leg, on the back, or posterior side of the thigh. The inner, or medial group is made of two muscles, the semimembranosus and semitendinosis, and the outer, or lateral group is made up of one muscle, the biceps femoris. The biceps femoris actually has two parts, or "heads", a long and a short, which can be seen anatomically as two separate muscles. Except for the short head of the lateral hamstring muscle, the hamstrings all originate at the ischial tuberosity of the pelvis, or sit bone. The short head originates at the lateral femur. The semimembranosus inserts, or ends, at the medial, (posterior) back side of the upper tibia, the semitendinosis at the medial, more anterior surface of the tibia, and the two parts of the biceps femoris insert at the lateral side of the fibula. Tendons attach the muscles to the bones, and can be injured as well.

The hamstrings help us move as in running and walking. Looking at them anatomically, they create this movement because they extend the hip and thigh, and they also help bend the lower leg on the upper leg. Throughout the stride they are either contracting or lengthening according to the changing positions of the hip and knee. This function is complex, but we can identify the stride postions that create the greatest risk of injury, as described in the next paragraph. Also, the hamstrings have a function when we are just standing still- they help us remain upright against gravity by exerting a backward pull on the pelvis. This is an 'antigravity' function, and is important for proper posture.

Most muscle injury such as in the hamstrings can be classified according to how it occurs, as either acute (sudden) or chronic (over time). The first type, an acute hamstring injury, can occur during the rapid stretching (lengthening) of the muscle, or during the rapid contraction (shortening) of the muscle. The part of the stride when rapid stretching occurs and injury is possible is when the leg swings foward near the end of the stride. During this time, we are flexing the thigh and simultaneously extending knee, stretching the hamstring from both ends, and tearing can occur. The part of the stride when rapid contraction occurs and injury is possible is during late push off. During this time, the hamstrings rapidly change from stabilizing the knee during the support (foot on the ground) phase to extending the hip as the knee flexes. The lateral hamstring is most likely injured at this time. In either case, as the injury occurs you feel immediate pain, usually described as a "pulled muscle". The location of the tearing is usually high in the thigh, near the where the muscle meets the tendon, or slightly below, towards the middle of the muscle. The injured area will feel sore to the touch, and the torn fibers may present themselves as a lump of tissue. The area may or may not be swollen. The tears can be graded as mild (grade 1), moderate (grade2), or severe (grade 3) depending on the amount of tearing. Fortunately for distance runners, these sudden types of injury usually occur during sprinting sports which require sudden, explosive movements, such as football, baseball and the track and field sprints. One exception, however, is when a runner finishes a distance race with a sprint, which can suddenly overload the hamstrings, which are usually tight and fatigued by that time in a race. In that case the injury will resemble more of an acute tear.

The second type of injury, the chronic one, is the more common one for runners, especially in high mileage or older runners who have been running for years. The injury usually occurs more gradually. With distance running, slight muscle tightness in the back of the knee, where the hamstrings insert, may not cause pain. But when we use a muscle often over and over for an extended period, as in distance running, the individual fibers can start to get "stuck" to each other. Upon manual examination, painful "knots" or adhesions can be felt by hand. If not treated, they then can lead to shortening of the muscle lengthwise- muscle tightness. With this tightness in place, the muscle will not lengthen properly or contract as strongly when exercised. This can eventually cause pain when enough fibers become involved. In this situation the location of the tightness is usually very high or low in the muscle, or the tendon itself can have the scar tissue. This muscle fiber tightening usually occurs either over the course of one workout or over days or weeks. Examples of immediate causes are a longer run than you are used to, or a faster speed session. It is important to note that an area of chronic tightness and/or weakness is often more susceptible to also suffering an acute tear during an end of a race sprint as described above.

Before a diagnosis of chronic hamstring injury is reached, other conditions such as sciatic nerve irritation or a pelvis stress fracture should always be ruled out. However, two injuries can exist at once, and can be related, so the hamstrings should be checked anyway if the other pain sources are found.

There are several reasons the hamstings are injured in sports. First, there is muscle imbalance, meaning one muscle is stronger than its opposite functioning muscle. In this case, the quadriceps, which extend the knee and flex the hip, are the opposing muscle group to the hamstrings, which flex the knee and extend the hip as mentioned above. If the quadriceps are overly developed in comparison to the hamstrings, the hamstrings must work harder to pull against the quadriceps, and can strain or tear if they are not strong enough. This is often the case in sprinting injury. The other common imbalance is the hip flexors being tighter than the upper hamstrings and gluteus maximus, which are the hip extensors. This is more often the case in distance running. In this case the upper hamstring will have to contract harder and can gradually tighten or become strained.

The next predisposing factor is adhesion formation, in the hamstrings and also in related muscles. As noted above, the adhesions will cause tightness and pain, with the tightness leading to more pain and so on. If untreated, then with the decreased elasticity there is even less range of motion, and the uninjured fibers will have to work harder, causing them to tighten and form new adhesions. This makes the chronic injury more likely to keep occuring. Also, muscular adhesions in the related hip muscles (gluteals, piriformis) can refer pain to the hamstrings. This can cause a feeling of hamstring strain, when none is really present, or both the hamstrings and the hip muscles can have adhesions. Also, the sciatic nerve can be "caught up" in hamstring adhesions, or further up above in the hip muscles, and either problem can further tighten the hamstring or simulate the feeling of a strain.

The third factor is pelvic alignment problems. Many people have postural distortion in the form of a lumbar spine or pelvic rotation and tilting, which causes an apparent "short leg" as one side is higher or lower than the other. Everyday activities may or may not be painful, but when subjected to the repetitive stresses of training for a marathon, the result can be muscle injury. The hamstrings can be overstretched on one side in this case, often the "long"side, and the gradual or acute type of hamstring injury then can occur.

Treatment of hamstring injury will vary depending on the both the degree of injury and which of the above predisposing factors need to be addressed.

In acute injury, self-treatment will involve ice application, with a compression wrap and elevation, at least once a day. Ceasing running for at least 2 weeks even in a mild, grade 1 tear must be done as, training through the injury will not help, and recovery must come first. Cross-training with activities that keep the range of motion to the pain-free level can be done, such as the elliptical or stair machines. In grade two tears return to running may take up to 4 or 5 weeks, and in grade three 2 or 3 months. It is important to note that the amount of healing time can vary in different people. Soft-tissue manual therapy such as active release technique must be done to minimize scar tissue formation and adhesions, and can greatly speed up healing in all three grades of tears. If the adhesions are not broken up, then the tear will heal with less flexible tissue than normal, healthy tissue and re-injury or the chronic tightness will occur. In all cases, return to running should be gradual and include an extended warm-up period, and speed training should not be done until easy and mid-paced runs are completely pain-free. Third degree tears may require surgical intervention if the tendon is fully pulled off the hip bone. This is rare, but if it occurs immediate surgery is neccesary for proper healing.

In the chronic injury, the tightness must be treated by removing/reducing the adhesions in the muscle or where the muscle meets the tendon. Again, manual therapy will release the adhesions. The related muscles, such as the gluteals, piriformis, and hip flexors and also the adductors and calf muscles also should be checked. This will remove the adhesions as a pre-disposing factor. Also, the "referred hamstring pain" and sciatic nerve adhesion syndromes described above can be fixed by the active release technique.

In both the acute or chronic injury types, strengthening exercises should be done, which can help correct any predisposing muscle imbalance, but not until the manual therapy has released most of the muscle adhesions. First are gentle range of motion exercises, progressing to isometric contractions (no joint movement) and then full-range of motion with light resistance at first. Eventually, the hamstrings should be strengthened during the lengthening movement (which is when injury often occurs), which means squats, lunges, and even backwards running for short distances (40-50 yard repeats in a safe area). Plyometric, or jumping exercises can help ready the hamstrings for explosive movements such as in the final kick of a race, plus stengthen the muscle-tendon junction, where the chronic tightness/weakness often occurs. Exercises on the stability ball are also excellent for strengthening the core as the hamstrings are worked.

The last predisposing factor, lumbar and pelvic alignment problems, are fixed by spinal manipulation of the rotated lumbar vertebrae or ilium (hip bones). This will correct a "functional short leg". Anatomical differences in leg length can be treated with heel lifts, and overpronation, which can lower one side of the pelvis, can be fixed with orthotics. Removing lumbar joint restrictions also will help with uneven torso rotation which can cause an uneven stride, which can contribute to tightening of the hamstrings.

Hamstring injuries can be very stubborn and are often difficult to treat, but if the above factors are addressed, the chances of re-injuring an acute injury or struggling with the chronic one will be diminished.

The muscles to which the achilles tendon attaches are the gastrocnemius and soleus. When these muscles contract during the running stride, they function as plantar flexors (downward motion of the foot), which gives us propulsion forward. When they stretch during the running stride, these muscles help in absorbing the impact of landing as the foot comes towards the knee. Also, since the gastrocnemius crosses the knee joint, when it contracts it helps in flexing your knee during the stride. The forces these muscles generate will affect and be affected by the health of your achilles tendon.

With the above anatomy and biomechanical information in mind, it is easy to see why the achilles is often injured. Common injuries are partial or complete rupture and tendinosis (scar tissue development). Until recently, overuse injuries to tendons such as the achilles were thought to involve inflammation. However, research has shown that there are no inflammatory cells present in most injured tendons. Instead, there are fibroblast cells, which form “scar tissue.” This scar tissue forms when the stress placed on the tendon is too great, causing degenerative microtears. Although the tears are “healed” with this new scar tissue, it is, unfortunately, not as flexible or resilient as the original tissue. Additionally, the most common area of injury to the tendon is about 2 cm above its attachment at the heel. It is thought that this area has less circulation and therefore is prone to the mircrotears.

Injury to the Achilles tendon can either happen suddenly, as in a rupture,or can occur gradually, as with tendinosis, which is the usual case in running. In the sudden injury scenario, recreational athletes often injure an already tightened or weakened calf when it is suddenly stretched or contracted past its normal limits, causing the tear. Although tears can occur in endurance athletes, the common scenario for a tear is a middle-aged person who has gradually lost flexibility and developed adhesions in the calf muscles and around the tendon, probably from years of sitting without regular stretching, and who goes out and plays tennis or softball for the first time in months or years. He or she then stresses muscles and tendon past their current limits, and a tear occurs. So even though the injury may seem sudden, the predisposing factor of decreased calf flexibility was probably present for some time. Likewise, in running and other endurance sports, a loss of calf flexibility and calf muscle/tendon adhesions are also to blame for cases of tendinosis.

To prevent overuse injury to the achilles, addressing the factors leading to tightness and possible scar tissue formation is necessary. Muscle tightness can be a major factor, and two areas are often the culprit: one is the calf, or back of the leg, as mentioned above, and the other is the adductor, or inner thigh muscles. Regular stretching and strengthening of these muscles (exercises described below) will help preserve normal foot motion and prevent overpronation. This is important to prevent, because overpronation, which is the ankle bone “rolling inward” at a greater than normal amount or speed, can overstretch the achilles. Overstretching causes the tendonosis by stressing the tendon and causing the tendon microtears and adhesions (the scar tissue). Tight calf muscles can cause a compensatory overpronation, to make up for the lack of leg bend at the ankle by flattening the arch more than normal. Likewise, tightness in the adductors can lead to the thigh moving inward while running, which then can cause our foot to turn outward, pronating excessively to compensate and keep us moving forward.Overpronation can also exist without any muscle tightness or imbalances, and lead to injury in the same way. Orthotics will correct the overpronation. Calf weakness can also be a factor, as lack of strength will cause overstretching of the achilles. Finally, training errors, such as doing too much speedwork or rapidly increasing training volume, can be causative. So can wearing worn out shoes, which can cause overstretching and tightness which will lead to injury. Unfortunately, often a runner often will only learn about these preventative measures once injured. The good news is that with proper treatment, even the worst cases can be resolved; however the earlier treatment starts, the better.

The type of treatment needed will depend on the stage of the injury. Depending on the severity of injury when treatment is initiated, at least one and as many as three weeks off from running are usually necessary. In the earlier stages of achilles injury, there is usually calf muscle and achilles tightness which causes tightness and pain with either contraction (push off) or stretching. This tightness must be addressed by techniques such as Active Release Technique, which reduces the muscle adhesions and increases flexibility. This reduces stress on the tendon, and often soreness there will decrease without direct treatment of the tendon. If the injury has progressed to swelling around the tendon, ice massage and electrical stimulation will help decrease the edema. This swelling is often felt as a “creaking” feeling when holding the tendon lightly and bending the foot up and down. Or, if the injury involves scar tissue formation, as in the athlete with a history of repeated episodes, cross-friction massage will be needed. Cross-friction works to increase the elasticity of the tendon by “breaking up” the scar tissue and restoring flexibility. Also, if there is restriction in motion of the ankle joint, manipulation of the ankle can help relieve stress on the Achilles. In this acute stage, taping for support and using heel lifts (in both shoes) to decrease stretch on the tendon will speed healing. All of these measures should greatly reduce the severity of the injury within three to six treatments, in most cases.

Once the acute pain stage is over—which means there is only mild to moderate tenderness over the tendon and no more pain on push off—the other factors named above must be addressed. This includes Active Release of any muscle tightness further up from the injury, such as in the adductors. The whole “kinetic chain”, from the leg to the hips, lower back, and even upper back, should be evaluated by analysis of the running form and treatment should address the imbalances found. Orthotics should be prescribed if overpronation is found, and worn-out shoes should be replaced. Stretching should be done the “active” way, by using a towel or stretching cord and contracting the muscles which oppose the calf. While seated with the legs out in front of you, actively contract the muscles in the front of your leg while using the towel or rope to assist near the end of the stretch. Hold for two to three seconds and repeat five to ten times. No pain should be felt at the tendon with these stretches. Stretches for the adductors or any other tight muscles, of course, should also be done. Strengthening exercises should include calf raises, with emphasis on the lowering, or “negative” part of the exercise. Standing on a step, raise up on the toes with both legs, and then lower slowly using a count of five to ten seconds. Repeat for ten repetitions and work up to three sets, after which weights can be added by using a calf-raise machine. Although it is doubtful that these guidelines could have saved the warrior Achilles, they could help save your running.

No matter if it’s your 1st or 50th marathon, a certain amount of time is required for our bodies, and minds (not to mention family and friends), to heal before the next race or season. Some say to allow one recovery day for every mile run- that means around 4 weeks after a marathon- to recover fully. Light stretching and walking is fine for the first few days. Then, easy running or cross-training with swimming, cycling, or water running after 3 to 7 days of inactivity is recommended to help heal the microtears in your muscles that cause most post-race soreness. If your legs still fell heavy, lifeless, and sore after a week of light runs or workouts, continue to go easy or take some more rest days. If not, you can run a little faster and longer the second week. Those who were either undertrained or overtrained, raced beyond their fitness level, or were fighting a specific injury before the race may need more recovery time than the more properly prepared and/or experienced runners.

Psychologically, some may “crash” to varying degrees the first few weeks after a big race, after months of having their lives structured around their training. A good way to recover mentally is to ease into some shorter races four or five weeks after, just for fun. This can give you a good transition into whatever winter activity you have planned. However, remember to keep any races fun; go easy! And, if you don’t really feel like you are ready physically, don’t race.

To avoid injury and recover fully, it may be helpful to think of the training year as a big circle, with the day after your last big race as the first day of the next season. This is because what you do now will determine what you can do over the winter months, which will then determine what type of shape you are in when your next race arrives. If you are planning to run some “off-season” winter races, you should keep some type of aerobic base, even if you are not racing them. Most should decrease their weekly mileage and add some other forms of aerobic activity, such as swimming, cycling, deep water running, or cross-country skiing, in addition to an weight-training program that includes upper body and core (adominals, lower back, and hips) strengthening.

When should you start increasing running mileage again? The answer depends on what your goals are for next year. Those who plan to “peak” for two marathons next year, one spring and one fall, such as Boston and New York, or have an early season triathlon, will want to start building a base earlier, such as January. But even if you are not racing “long” until next fall, don’t wait until July to start building back your base, as you will leave less room for error and more room for injury. Ideally, for a fall marathon, you should reach half-marathon distance by the end of May, no matter what your ability level.

If you follow these steps, chances are you will avoid the common post-marathon injuries that often appear in the winter months, such as iliotibial band syndrome and stress fractures. Better yet, you will enjoy your winter racing or cross-training, and you will have both the body and the energy to “reach new peaks” next year

The first step is to test your ankle for the scar tissue. One way to do this is to self-test your ankle for tenderness, restricted range of motion/muscle tightness, and decreased balance ability. As presented in part 1, there are two main groups of ligaments in the ankle, the lateral (outer) group, and the medial (inner) group. It may help to look at the diagrams from part 1. To test the lateral ligaments, start by locating the end of your fibula, which is marked by a thickening of bone called the lateral malleolus. Then run your fingers forward about half an inch, and you will be on the most commonly injured ankle ligament, the anterior talofibular ligament. Often only mild pressure is necessary to note some tenderness. Compare both ankles simultaneously. If one side is tenderer, there may be a problem with the ligament. For the remaining two lateral ligaments, you have to move your fingers straight downward and slightly backward from the lateral malleolus and test for tenderness there (calcanealfibular ligament), and also move straight backward from the malleoulus about half an inch and test there (posterior talofibular ligament). For the medial ligaments, find the medial malleolus, which is the thickened bone on the end of the inner tibia. If you move your fingers forward half an inch, you will be on the anterior tibiotalar ligament. Slightly below that is the tibionavicular ligament. After checking for tenderness in these, again start at the medial malleolus and move straight down, and you will be on the tibiocalcaneal ligament. Finally, from the malleolus move straight back and slightly downward and you will be on the posterior tibotalar ligament. Again, for all these ligaments, compare left and right, noting any tenderness. Healthy ligaments are not painful to touch, even with relatively deep pressure! It is possible to have problems on both left and right sides. If you have difficulty finding the ligaments it may be necessary to seek help from a knowledgeable sports medicine professional.

The next step is to test for reduced range of motion. Two tests can be done. Don’t worry; no major anatomical knowledge is necessary for this one. Sit on the floor, with your legs straight out in front of you, and no shoes on. The first test is to just stretch your calf muscles by actively bringing your foot straight up towards your shin. Do this on the left and right simultaneously, looking for a decrease in the range of motion. You should be able to bring the foot up 20-30 degrees from the rest position. If you use a rope to pull even further, up to 45 degrees may be possible. If there is restriction, it may be in the calf muscles behind you leg, or in the ankle joint itself, or both. Tightness in the ankle joint may mean the ligaments have scar tissue that needs to be released, as the tissue is restricting the ankle bone (talus) from moving. If you only feel muscle tightness, then you may only have shortened calf muscles on that side. If the muscle has been tight for a long time or has had previous injury, it may also have scar tissue that needs to be released. The second test involves putting your foot on the ground, knees bent, and sliding them away from you. Do not let your heels come off the floor. One side may feel more limited. If it does, again it can be either in the joint or the muscles. In this test, the muscles in front of the leg are being tested.

The third self-test is for decreased balance ability. Standing barefoot in a doorway, bend one leg at the knee. You are testing the leg on the ground. If your balance is proper, you should be able to stand straight for 30 seconds without picking up on either the inside or outside of your foot and without your hands reaching side to side significantly for the doorway. As mentioned in part 1, scar tissue in the ligaments can alter your balance ability.

Now, if you have found problems, fixing them usually involves a combination of professional treatment and self-treatment with exercises. When I look for this hidden ankle dysfunction in a patient, the same tests mentioned above are part of my exam. I also watch the patient walk and run, to evaluate how the ankle joint is moving in real life. This helps give a proper diagnosis of why the ankle is not working correctly and/or if the ankle is playing a role in injury elsewhere. The scar tissue will be more developed the more severe the original injury was, and the longer the period of immobilization that may have occurred. Even though it is optimum to get any injury treated as early as possible, the scar tissue can still be made more flexible and actually heal to be much more like the original ligament tissue if it is discovered later on.

To do this, treatment involves restoring length to the scar tissue, which then helps restore the range of motion to the ankle joint. This is done by soft-tissue techniques, such as Active Release Technique (ART) and cross-friction massage. In ART, the provider makes a specific finger contact at the site of the scar tissue, and then the ankle is moved to create tension on the ligament as the provider maintains the contact. The contact and tension is in line with the fibers of the ligament. This combination of tension and movement “breaks up” the scar tissue, restoring proper length and strength to the ligament. In cross-friction massage, the scar tissue is broken up by a finger or massage tool contact moving across the fibers of the ligament. All the ligaments, plus the joint capsule, must be evaluated.

Once the scar tissue in is treated, the muscles are checked. Scar tissue in the muscles is often called “adhesions”. ART is very effective at breaking up the muscular adhesions as well. Besides the calf muscles, the rest of the body must be checked. With chronic ankle injury, there often can be a reflex weakening of the gluteus medius, or hip abductor, so it may have adhesions and weakness. Also, the original ankle injury may be related to a nerve problem (sciatic nerve, for example) anywhere from the ankle to the lower back, as nerve entrapment can weaken the leg muscles and pre-dispose to a sprained ankle. Thus the back should also be evaluated and treated as necessary.

Once you have been treated, stretching exercises must be done to maintain the increased range of motion. To stretch the gastrocnemius muscle in the back of the leg, use a towel or rope, just as in the range of motion test described above. Actively move the foot towards the shin, using the rope to assist the last quarter of the stretch, and hold for 2 seconds. To stretch the soleus muscle, which doesn’t cross the knee joint, bend your knee and then use your hands to pull the foot upward. There will not be as much movement in this stretch. To stretch the tibialis anterior in front of the leg, from a sitting position, bend the leg to be stretched and place the leg over the straight leg above the knee. Then take your opposite hand and pull the foot downward gently and holding for 2 seconds. Repeat all of these stretches 5-10 times, attempting to move further each time but not forcing the stretch.

Strengthening exercises include using elastic tubing in two ways. One is to do small movements for 10-60 seconds. Small movements help improve coordination, as well as strength and endurance. Start in the middle of the range of motion of the exercise and move 5-10 degrees in both directions. Speed can be increased as endurance is gained. In the beginning you may only be able to do 10 seconds before fatigue sets in. Do a total of 60 seconds, by building up to 2 x 30 seconds. The other tubing exercise is to do full range of motion for either time or repetitions. Internal rotation, external rotation, plantar flexion and dorsiflexion all can be done for these exercises.

Balance exercises must also be done, to restore the lost proprioception that occurs with chronic ankle injury. First, simply repeat the self-test described above, for a total of 60 seconds standing (2x 30 seconds). Once this is easy, try with the eyes closed. Then, balance boards and rocker boards also can be used.

If hip or lower back/core muscle weakness was found with examination, then strengthening for those areas must be done as well. Once all weak areas have been strengthened and balance ability improved, running drills and plyometric (jumping) exercises for coordination, power and agility can be added. This complete approach, starting with removing soft-tissue restriction, then improving range of motion, strength, and balance, can help the body heal hidden ankle injury and the problems it may lead to along the kinetic chain.

In general, addressing the physical stress of running on the lower back involves maintaining the core strength and overall flexibility reviewed in the above information on anatomy. However, there can be differences in the type of lower back pain experienced by beginner runners and veteran runners. Beginners and those who have not been running in a while often have pain from tightness and weakness in the lower back extensor muscles, especially when running hills. Pain may be present only during the run, and may or may not disappear as you warm-up. The solution can be as simple as adapting to running again; as conditioning improves the pain should decrease. However, if you have been really inactive or if pain persists after a few runs, core strengthening and general flexibility work are probably needed.

In veteran runners- especially in marathoners, muscle imbalances can lead to lower back pain and/or sciatic type pains in the buttocks, hips, hamstrings and calves. Distance running tends to tighten these muscles, as do many other activities, such as sitting at work, and after many years of both activities pain can develop. Pain down the legs can be "psuedosciatica", referred from restricted spinal joints of the lower back and/or from "trigger points", which are knots in the muscles of the lower back, hips and legs. However, disc problems can irritate the spinal nerves and cause "true sciatica" with pain anywhere along the path of the sciatic nerve.

In beginners and veterans alike, the type of treatment necessary depends on if the pain and injury is in the acute or chronic stage. For example, a runner might ignore the warning signs of persistent muscle tightness after longer runs, and eventually experience pain, either during or after a run, that is very severe and incapacitating. Treatment will start with reducing or stopping training and applying ice to the area to reduce pain, swelling and spasm. Office treatment will include electric muscle stimulation, ultrasound heat treatments, and chiropractic adjustments, to get the tightened muscles and joints moving again. Next are pain-relief stretches. The exact exercises to be done in cases of acute lower back pain are very specific to each individual’s injury. Some people need "flexion exercises" and some people need "extension exercises" to help mobilize the spine and relieve pain, and this is decided with the help of the doctor. Once the pain relief stage is over, corrective exercises and joint and muscle balancing techniques must be done to prevent re-injury, just as in chronic injury, which is described below. It is important to note that anti-inflammatory medication or steroid injections may help in relieving the acute pain in some cases, but should never be the end-point of treatment, as they do not address the underlying, functional causes and leave one open to re-injury.

Treatment of chronic LBP in runners must address the functional imbalances that cause pain themselves or allow degenerative joint and disc problems to become symptomatic. This involves identifying which muscles are tight and/or weak, and which joints are not moving properly. Common muscle patterns involve tight hip flexors, especially the upper quadriceps and psoas muscle, with weakness in the opposing hip extensors (gluteus maximus and upper hamstring) muscles, or tight lower back extensors with weakness in the opposing lower and deep abdominals. These are some of the vital “core” muscles mentioned in part one. Further down, the lower hamstrings and calf muscles are often tight. Also, the hip abductors (outer hip) are often weak and the adductors (upper, inner thigh) tight. Before the weak muscles can be strengthened, the tight ones must be stretched. Office treatment involves manual release, such as Active Release Techniques, of muscle trigger points and adhesions, which is often essential in restoring proper flexibility and strength. Then, stretching can be done with assistance, as part of office treatment, and by using self-stretching techniques at home, such as active-isolated stretching. As for joint restriction, the lower thoracic and all of the lumbar vertebra, plus the sacroiliac (between the hip bones and sacrum) joints, are often involved. Office treatment includes spinal and extremity adjustments to restore normal joint motion and coordination.

Once normal muscle length is restored, strengthening and stabilization exercises are added, starting with isometric deep abdominal and deep back extensor contractions, and progressing to holding this core tight while performing arm and leg movements, and then to exercises such as standing lunges and squats. Balance exercises and full-body movements such as pull-ups and push-ups are also beneficial, as they strengthen the upper back, which is essential in maintaining an upright posture during long runs.

Other factors that need to be addressed for successful management, if they exist, include correcting overpronation and leg-length inequalities with orthotics and/or heel lifts. And, of course, training errors must be examined, such as too many hills when just starting to run or after a layoff, worn out shoes, only running on pavement, too many long runs in a marathon training plan or not enough recovery between long runs.

This program of treatment will prevent the cycle of minor joint strain and muscle tightening, pain, emotional disturbance, and further physical damage from occurring. It will keep the healthy muscle tissue from being damaged and replaced with fibrotic scar tissue, which is less elastic, weaker and more prone to injury.

Because this information is often learned only after serious injury and training interruption, an earlier understanding and proper intervention may make it easier to keep your back, and your training, on track.

Alright, enough of the bad news about the challenges we face when it comes to the back. What can be done about it? Education, prevention, and proper and early treatment are the keys to a healthy spine. First, here is a quick review of normal spinal anatomy and how the spine should function.

The spine is made up of 24 movable vertebrae, with 7 in the neck (cervical), 12 in the upper and middle back (thoracic), and 5 in the lower back (lumbar). Nerve roots exit left and right at each level. Additionally, the sacrum and coccyx form the base of the spine. The hip bones articulate with the sacrum, forming the sacroiliac joint, which is often a problem area in runners. Intervertebral discs, which are made up of a semi-liquid center surrounded by a tougher, fibrous layering of cartilage (think of a jelly donut) are placed between each vertebrae to cushion and guide spinal motion. Ligaments run up and down the spine, front and back, and add further stability. Finally, three layers of muscles attach from the the sacrum up to the neck and allow us to bend in all directions and also, provide for a strong “core” from which to move off of. The abdominals, olbliques and latissimus dorsi also provide this core strength, and strong and flexible hamstring, calf and hip and shoulder girdle muscles allow us to move without strain on the back.

Now, what causes all of these muscles and joints to stop working together as they were designed to and leads to the pain? As in most health problems, a combination of structural, chemical and emotional stressors eventually overwhelms the body and leads to tissue breakdown. Repetitive physical stressors and such as prolonged sitting or bending wrong strain and tighten spinal joints, decrease circulation, raise the pressure on our intervertebral discs, and tighten key muscles. Chemically, a diet deficient in “anti--inflammatory” foods such as unrefined oils (fish/olive), fruits and vegetables makes tissues more acidic and painful. Emotions such as anxiety, fear, and depression can further restrict blood flow and tighten muscles, lowering their tolerance for the physical stressors. Thus, a cycle of minor joint strain and muscle tightening, pain, emotional disturbance, and further physical damage occurs. Healthy muscle tissue becomes replaced by fibrotic scar tissue, which is less elastic and weaker. In the general population, when the above lifestyle factors are not being addressed, acute injury or chronic pain often is the result. Unfortunately, in either case often the process is developing for a while before the symptoms start, and pain may be the first sign that something is not working right. Running, although it counteracts some of these modern stressors and strengthens the body, still can lead to or be affected by back pain.

Strategies for the prevention and proper and early treatment of lower back pain in runners are discussed in part 2 of this article.

Thus, whenever an athlete is being evaluated for a running injury or is just seeking better performance, the biomechanical function of the ankle joint must be examined. Proper treatment, rehab/strengthening exercises and training then can occur. This article will show how hidden ankle dysfunction can occur, and next month in part two the treatment and exercises will be covered.

Some possible ankle injuries, from the more common to less, are sprained lateral (outer) or medial (inner) ligaments, injury to the tendons crossing the ankle, and even fractures to the talus or calcaneus. The ankle is among the most commonly injured joints in athletics. Cross-country running is one of the sports usually involved, along with basketball, football and soccer. A little anatomy: The talus is the ankle bone, and it sits between the tibia (inner leg bone) and fibula (outer leg bone) and the bones of the foot. The calcaneus is the heel bone, and meets the fibula, talus and foot. Ligaments connect bone to bone, providing stability, and there are two major groups at the ankle. The lateral group connects the fibula to the talus and calcaneus, and the medial group connects the tibia to the talus, calcaneus and the navicular (one of the foot bones). Tendons, which attach muscle to bone, cross the ankle joint and give added stability as well. The peroneal tendons, from the peroneal muscles, are on the outside, the tibialis anterior and toe extensor tendons are in front, the Achilles (from the gastrocnemius and soleus muscles) is in the back, and the tibialis posterior and toe flexor tendons are on the inside. The tendons are held in place as they cross the joint by thin coverings called retinaculum. Finally, there is the joint capsule, a ligament-like tissue that surrounds the joint for some added stability.

When a patient comes in with an acutely sprained ankle or other ankle complaint, ankle involvement is obvious. But sometimes it is not, and it is often the ligaments, capsule, or retinaculum that has hidden problems. For example, often a runner will complain of knee pain or some other injury, and not mention any recent ankle injury when questioned. However, by examining each and every anatomical structure described above, hidden ankle problems can be found. For example there is often tenderness to palpation at key ligaments, indicating something going on with that ankle. Usually the patient then remembers that they once injured the ankle. If they can’t remember the original injury, then they are even more surprised at how sore the tissue is (and let me know it). The original injury could be as far back as a year, or even five or ten years. Why, then, does the ankle remain tender after all that time?

Scar tissue formation in the ligaments or capsule is often to blame for the tenderness. For example, let’s take an ankle sprain, the most common ankle injury. A sprain means you have overstretched some of the fibers that make up the ligament. Swelling may or may not occur, which is why sometimes a light sprain may not seem like that big a deal at all. However, with or without major swelling, the body will attempt to heal the area by laying down new tissue within the ligament- just as a cut will heal. Unfortunately, this “scar” tissue is not as strong, flexible or reactive as the original tissue. Often treatment just addresses the immediate swelling, but the scar tissue remains unless it is treated. This means the “scarred” ligament will not support the joint as well, which leads to abnormal ankle joint motion. Usually there is decreased range of motion when the foot is landing and pushing off. This, in turn, can lead to shortening of the calf and leg muscles. Thus, the function of the leg and then the entire kinetic chain can be affected. Pain and injury can then occur anywhere along the chain- a chronic or re-occurring hamstring strain may be the result, for example, and will not heal fully unless the ankle is checked.

Because it is weaker, less flexible and decreases balance ability, the scar tissue also predisposes the ankle itself to re-injury. With less strength, the scarred ligament has less resistance to overstretching. The decreased range of motion makes the ankle less stable. For the lateral ligament the effect of this limited range of motion is easy to feel: in the calf-stretched position (called ankle dorsiflexion), it is harder to “turn your ankle”, but the ankle turns easily in the toe-down position (called ankle plantarflexion). If you lose calf flexibility, you are more likely to be in the less stable plantarflexion position when you are out there running. Finally, usually your balance will now be worse on the injured side, as the function of the ankle’s proprioceptors is diminished. Proprioceptors are nerve receptors located in the ligaments, joint capsule and muscle tissue. They tell your brain how stretched a muscle is and at what angle a joint is at a given moment, so that the nervous system can alert the muscles to make stride adjustments. The scar tissue decreases the performance of these nerve receptors. In other words, if you hit uneven terrain, you will be more likely to turn your ankle.

In part two of this article, how to treat the scar tissue and restore normal biomechanics of the kinetic chain will be covered.

First of all, the side effects of medications such as Advil, Aleve and Nuprin, which are called NSAIDS (non-steroidal anti-inflammatory drugs), should be considered. A small amount of gastrointestinal bleeding occurs each time that NSAIDS are taken. In some people this can lead to ulcers and perforation of the gastrointestinal lining. Thus abdominal pain when taking NSAIDS should be taken seriously.

Recently, another side effect has been getting more attention and that is the effects of NSAIDS on the kidneys and the onset of hyponatremia, which is a lowering of the sodium levels in the blood, a very dangerous condition. These drugs work by inhibiting the action of an enzyme that is responsible for the inflammatory process, thereby reducing pain. But the same enzyme is also responsible for helping the kidneys to retain electrolytes, which is already a challenge during endurance sports. Thus, the ingestion of these drugs could contribute to hyponatremia.

Next, pain should be considered a warning sign, whose cause is to be investigated. Covering up your symptom of pain with medication can lead to more serious injury. New research has revealed that many overuse injuries aren’t even inflammatory in nature! Many tendon injuries have been found to involve degeneration of the collagen material making up the tendon, with no inflammatory cells present on biopsy. This is called tendinosis, not tendinitis, and will not be helped by trying to limit inflammation. In fact, Advil and the rest of the over-the-counter drugs may even delay healing of connective tissue and muscle, even though you may feel less pain.

What is the better approach? As for the event of day, remember that while participating in athletic events is supposed to be a healthy endeavor, the physical demands on the body can be tremendous. Endurance racing, for example, can involve the experience of some stiffness during the race, which you should not mind running with. The way your body feels at different points of a race is part of the challenge of the race, and it is much safer to “listen to” the level of tightness or pain you have than to hide it with NSAIDS. Pain that is more intense should not be numbed with medication so that you can “run through” it, as more serious injury and lost training time may result. Remember, mild to moderate stiffness usually will be gone when you finish, and most post-exercise soreness will disappear within a few days after the race.

If you are injured, it may be better to rest until the next race if you haven’t fully recovered. This approach involves determining, to the greatest extent possible, the true cause of the injury. Muscle tightness and weakness, poor foot mechanics (overpronation/underpronation), improper footwear, training too far, fast or often are just a few examples of correctable causes of overuse injuries. As noted above, the injured tissue is often not inflamed. Instead, tendons often have scarring in them (their fibers become less elastic and less flexible), and muscles are often tightened. Treatment must involve rehabilitating the injured tissue, which will eliminate the cause of the pain, instead of masking it with medication and risking serious side effects.

This article is for informational purposes only, and should not be used as personal advice or diagnosis without first consulting a health-care professional. If you have, or suspect you have a health-care problem, then you should immediately contact a qualified health-care professional for treatment.

As noted above, chiropractic care involves looking at the athlete as a whole person and seeks to eliminate the cause of the problem, not just the symptoms. When an injured athlete enters my office, I start with a thorough history of the injury and the events surrounding it, including past and present health, training history, diet, and other stress factors. Next, I perform both a local exam of the area of complaint and a comprehensive biomechanical evaluation, testing for postural faults and muscle balance of the spine and extremities. I also watch the athlete walk and run and evaluate their running shoes. Bike fit and swimming technique also are addressed. In other words, your body structure is assessed to see how it is functioning. Thus, the specific tissue causing the pain, as well as any areas of weakness or imbalance above or below that may have caused that tissue to breakdown are addressed.

For instance, you may have the symptoms for patellar tendonitis, yet the real cause may be tightness of certain hip muscles with restriction of movement in the lower back. If treatment is just directed at the painful knee, the symptoms may abate for a while, but since the underlying cause hasn’t been corrected, the injury may reoccur when training is resumed. This can be very frustrating, as it is hard to train and improve while constantly recovering from one injury or another.

Treatment involves correcting the dysfunctions found. Manual muscle therapy, such as Active Release Techniques, removes adhesions in the fascia and muscles that cause tightness, weakness, and eventual tendon and joint stress. Adjustments of the joints of the spine and extremities remove joint restrictions and normalize neurological function, which also can help restore muscle length. Therapeutic stretching and modalities such as electric muscle stimulation and ultrasound may be utilized. Specific rehabilitative exercises and training advice are also given, including proper core strengthening and weight training. Nutritional changes may also be recommended.

Training involves a balance between breaking down our bodies and letting them recover and get stronger. When we overdo it, the stress is often stored in the muscle and joint restrictions occur described above. Thus, chiropractic care gets results because it removes this stress and allows us to recover faster and return to training again.

This article is for informational purposes only, and should not be used as personal advice or diagnosis without first consulting a health-care professional. If you have, or suspect you have a health-care problem, then you should immediately contact a qualified health-care professional for treatment.